Shift Report

I have found that going through the systems helps decrease omissions when giving reprot (any kind). You may want to experiment with it and see if it works for you; Neuro, CV, Resp, GI/GU, Skin, labs, misc.

Thanks!

Does your unit utilize computer charting or flow sheets? If it is flow sheets I suggest you give report at the chart so that if the nurse following you has questions you can refer to your charting. This way you can be more accurate and save time because you won't have to spend time writing your assessments for report.

Here are some tips on what I like and don't like in report.

Time wasters: Normal vs, how many visitors and how long they stayed, when scheduled IV antibiotics are due, ect, ect. Please let me know ABNORMALS and what the interventions were and if you notified the doctor.

Time savers: Past hx. I like to know if our patient has a history of CHF or HTN (hmmmm...why are we running ns at 200cc @hr?) and recent test results and abnormal labs. Hmmm.. Pt has a K+ level or 3.2 and the doc hasn't wrote new orders-----time to get an order for potassium. Hgb is 8.5- what was it yesterday. Has the doc been notified? Assessment changes- pt with exacerbation of COPD now has increasing crackles- maybe we need to see if they need lasix. These types of things are important to me when receiving report. Hope these tips help. you will develop your own system in time.